Severe overcrowding in KwaZulu-Natal’s prisons is contributing to the spread of HIV and tuberculosis and driving the high death toll in prisons, according to King Kumalo, provincial deputy director of health services in the Department of Correctional Services (DCS), in his address to the annual meeting of Hospice Palliative Care Association on 1 September 2010. So far this year, 120 prisoners have died of ‘natural causes’ (diseases) and eight of unnatural causes in KwaZulu-Natal, he reported. In the past, there were more unnatural deaths such as murder and suicide than natural deaths, said King. Last year, 168 prisoners died of natural causes while 14 died of natural causes. As a result of the high death toll, the DCS has brought in hospice workers to assist them to treat people with advanced disease who are in need of pain relief. The HPCA, cares for over 70,000 patients at 200 sites countrywide, also has a memorandum of understanding with the SA National Defence Force to provide palliative care (pain relief). However, hospice workers reported that HIV and TB – particularly drug-resistant TB - were challenging their resources. A shortage of beds for patients, long travelling distances to treatment centres were cited as obstacles, while many of the local clinics were reported to not offer monthly tests on people with drug-resistant TB because staff are scared of becoming infected.
Equitable health services
This study took the form of a process evaluation of the tenfold scale-up of an evaluated Youth Friendly Service (YFS) intervention in Mwanza Region, Tanzania to identify key facilitating and inhibitory factors from both user and provider perspectives. The intervention was scaled up in two training rounds lasting six and ten months and evaluated through a simulated patient study, focus group discussions and semi-structured interviews with health workers and trainers, training observations and pre- and post-training questionnaires. The study found that, between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time trainers' confidence and ability to lead sessions improved. The scale-up faced challenges in the selection and retention of trained health workers, however, and was limited by various contextual factors and structural constraints. The study concludes that YFS interventions can remain well delivered even after expansion through existing systems. The scaling up process did affect some aspects of intervention quality and the findings emphasise the need to train more staff (both clinical and non-clinical) per facility in order to ensure YFS delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale-up.
This paper presents the results of a feasibility study of a fully integrated model of HIV and non-HIV outpatient services in two urban Lusaka clinics. Assessment of feasibility included monitoring rates of HIV case-finding and referral to care, measuring median waiting and consultation times and assessing adherence to clinical care protocols for HIV and non-HIV outpatients. Provider and patient interviews at both of the sites in the study indicated broad acceptability of the model and highlighted a perceived reduction in stigma associated with integrated HIV services. The paper argues that integrating vertical anti-retroviral therapy and outpatient services is feasible in the low-resource and high HIV-prevalence setting of Lusaka, Zambia. Integration enabled shared use of space and staffing that resulted in increased HIV case finding, a reduction in stigma associated with vertical ART services but resulted in an overall increase in patient waiting times. Further research is required to assess long-term clinical outcomes and cost effectiveness in order to evaluate scalability and generalisability.
The objective of this study was to assess the relationship between the prevalence of vitamin A deficiency among pregnant women and the effect of neonatal vitamin A supplementation on infant mortality. The study’s literature review revealed that studies of neonatal supplementation with vitamin A have yielded contradictory findings with regard to its effect on the risk of infant death, possibly owing to heterogeneity between studies. One source of that heterogeneity is the prevalence of vitamin A deficiency among pregnant women, which the study examined using meta-regression techniques on eligible individual and cluster-randomised trials. The meta-regression analysis revealed a statistically significant linear relationship between the prevalence of vitamin A deficiency in pregnant women and the observed effectiveness of vitamin A supplementation at birth. In regions where at least 22% of pregnant women have vitamin A deficiency, the study recommends giving neonates vitamin A supplements to help protect against infant death.
In this study, malaria prevalence and morbidity were monitored in two villages in north-eastern Tanzania – a lowland village and a highland village from 2003 to 2008. Trained village health workers treated presumptive malaria with the Tanzanian first-line anti-malarial drug and collected blood smears that were examined later. The prevalence of malaria parasitaemia across years was monitored through cross-sectional surveys, and was found to decrease in the lowland village 78.4% in 2003 to 13.0% in 2008, while in the highland village, prevalence dropped from 24.7% to 3.1% in the same period. Similarly, the incidence of febrile malaria episodes in the two villages dropped by almost 85%, with a marked reduction in anaemia in young children in the lowland village. According to the study, this decline is likely to be due to a combination of factors that include improved access to malaria treatment provided by the trained village helpers, protection from mosquitoes by increased availability of insecticide-impregnated bed nets and a reduced vector density. If this decline in malaria morbidity is sustained, it will have a marked effect on the disease burden in this part of Tanzania.
This is a comparative case study of the early management of ART scale up in three South African provincial governments – Western Cape, Gauteng and Free State – focusing on both operational and strategic dimensions. Drawing on surveys of models of ART care and analyses of the policy process conducted in the three provinces between 2005 and 2007, as well as a considerable body of grey and indexed literature on ART scale up in South Africa, it draws links between implementation processes and variations in provincial ART coverage (low, medium and high) achieved in the three provinces. While they adopted similar chronic disease care approaches, the study found that the provinces differed with respect to political and managerial leadership of the programme, programme design, the balance between central standardisation and local flexibility, the effectiveness of monitoring and evaluation systems, and the nature and extent of external support and programme partnerships. This case study points to the importance of sub-national programme processes and the influence of factors other than financing or human resource capacity, in understanding intervention scale up.
The metric of ‘bed numbers’ is commonly used in hospital planning, but it fails to capture key aspects of how hospital services are delivered. Drawing on a study of innovative hospital projects in Europe, this article argues that hospital capacity planning should not be based on beds, but rather on the ability to deliver processes. It proposes using approaches that are based on manufacturing theory such as ‘lean thinking’ that focuses on the value that different processes add for the primary customer, i.e. the patient. It argues that it is beneficial to look at the hospital, not from the perspective of beds or specialties, but rather from the path taken by the patients who are treated in them, the respective processes delivered by health professionals and the facilities appropriate to those processes. Systematised care pathways seem to offer one avenue for achieving these goals. However, they need to be underpinned by a better understanding of the flows of patients, work and goods within a hospital, the bottlenecks that occur, and translation of this understanding into new capacity planning tools.
High blood pressure in South Africa is estimated to have caused 46,888 deaths and 390,860 disability-adjusted life years in 2000. Yet, according to this paper, detection and management of hypertension remains suboptimal due to inadequate public health care facilities. Mass rural to urban migration and rapid changes in lifestyle and risk factors account for the rising prevalence of hypertension, but genetic factors may also play an important contributory role. Black South Africans also appear to be more prone to complications of hypertension, particularly stroke, heart failure, and hypertensive nephrosclerosis, and respond poorly to ACE inhibitors as monotherapy. Proactive public health interventions at a population level need to be introduced to control this growing epidemic.
Research presented at the Eighteenth International AIDS Conference, held from 19–27 July in Vienna, Austria, appears to indicate that the impact of HIV spending on other major health problems, particularly the Millennium Development Goals on child mortality and maternal mortality, has been limited to date, despite compelling evidence of the impact of HIV on child and maternal mortality, particularly in southern Africa. Other studies presented at the Conference were less clear-cut in their findings. For example, research in Rwanda, which compared 26 pairs of health centres – one providing HIV care and the other not – found that, although centres providing HIV care showed a trend towards better outcomes with regard to a range of indicators including child immunisation, adult and child hospitalisation and curative visits to the health centre, the only indicator on which HIV clinics did significantly better was providing BCG vaccinations to all patients. Researchers agreed that more research was needed, looking in particular at a wider range of settings and services, and taking into account the effects of other recent global health initiatives, notably GAVI, which has been supporting the purchase of vaccines for child immunisation.
The objectives of the Health Sector Support Project (HSSP) for Kenya, which is funded by the World Bank, are to improve: the delivery of essential health services for Kenyans, especially the poor; and the effectiveness of planning, financing and procurement of pharmaceuticals and medical supplies. There are two components to the project, the first component being effective and transparent implementation of the Kenya Essential Package for Health (KEPH) through Health Sector Services Fund (HSSF) grants and performance strengthening. The project will support the effective implementation of the KEPH, through financing the HSSF targeted at health service delivery levels one, two, and three. The HSSF aims to improve the delivery of quality essential services, especially at the sub-district and community levels, in an equitable and efficient manner, through: generating and providing sufficient resources for implementing each facility's Annual Operational Plan (AOP) to address preventive, promotive, and curative services at levels one, two, and three, and to account for them in an efficient, and transparent manner according to current government systems; and supporting capacity building in the management of health facilities. Finally, the second component is the availability of essential health commodities and supply chain management reform. This component will be implemented in parallel with the HSSF, to ensure an improved availability of commodities in, and enhance the quality of care provided at, the lower levels of the public health system.